- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $970.54 / $970.54 / $1,164.65
| Facility | | $970.54 | $970.54 | $1,164.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.89 / $970.54 / $1,005.44
| Professional | | $115.89 | $970.54 | $1,005.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.20 / $700.20 / $1,021.20
| Professional | | $700.20 | $700.20 | $1,021.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.60 / $750.60 / $750.60
| Professional | | $750.60 | $750.60 | $750.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.67 / $80.83 / $261.16
| Professional | | $41.67 | $80.83 | $261.16 |